Enquiry Form

Title*
Mr Mrs Miss Dr Ms

First name*

Address 1 *

Town

Postcode *

Date of birth: *

Surname*

Address 2

County

Country

Preferred contact*

 Email    Post    Telephone  

Email address: *

Telephone Number:

Confirm email address: *

Time of day to call:

Home insurance renewal date: *

Age of property: *

Type of property: *

 Detached house    Semi-detached house    Detached bungalow  

 Semi detached bungalow    Terraced    Flat  

Number of bedrooms: *
[Select] 1 2 3 4 5 6 7 8

Current premium:

Leek United Building Society account number

(if applicable)

Do you currently have buildings insurance?

 Yes    No  

Do you currently have contents insurance?

 Yes    No  

Do you currently have personal possessions insurance?

 Yes    No  

Do you currently have legal expenses insurance?

 Yes    No